What is the best treatment for a child with an acute tear of the anterior cruciate ligament?

With the heightened popularity of childhood sporting activity, the number of paediatric anterior cruciate ligament (ACL) ruptures has increased. Management of these injuries presents a particular challenge due to the open femoral and tibial growth plates. Physeal damage has the potential to cause angular deformity or length discrepancy. This review was conducted to determine the best way to treat this injury. A primary search of Ovid MEDLINE (1 October 2017) used the terms: (ACL or anterior cruciate ligament) and (young or child or children or pediatric or immature or pre-pubescent). Titles/Abstracts of 369 articles were screened for relevance. A total of 217 were excluded, leaving 152 articles for full-paper retrieval. Of these, 9 articles remained with one further article identified during cross-referencing; 10 papers (1 level 2 and 9 level 3) were included for analysis. Comparative studies investigating surgical (140 knees) versus conservative (110 knees) treatment provide evidence in favour of the former, in reducing instability and meniscal tears and improving return to previous activity. Of the papers analysed (163 reconstructions), there was only one case of growth arrest (0.6%) and no cases of length discrepancy. In those studies investigating early (218 patients) versus delayed (140 patients) reconstruction, medial meniscal tears and chondral injuries occurred more frequently in the delayed group. To conclude, for children, there is level 2/3 evidence that early operative ACL reconstruction offers the best chance of a return to pre-injury sporting activity and minimises the risks of further structural damage. Iatrogenic growth disturbance remains a rare but worrying complication.

Effects of Antibiotics on α-Toxin Levels during Staphylococcus aureus Culture: Implications for the Protection of Chondrocytes in a Model of Septic Arthritis.

OBJECTIVE: Septic arthritis results from joint infection by Staphylococcus aureus, which produces potent α-toxin causing cell death, potentially leading to permanent cartilage damage. Treatment is by joint irrigation and antibiotics, although it is unclear if, following treatment with antibiotics which cause bacterial lysis, there is release of additional stored α-toxin. DESIGN: A rabbit erythrocyte hemolysis assay was optimised to assess biologically-active α-toxin from cultured S. aureus α-toxin strain DU5946. Hemoglobin release was measured spectrophotometrically following addition of a bacteriostatic antibiotic (linezolid) or a bacteriolytic antibiotic (penicillin). A bovine cartilage model of septic arthritis was used to test the protective effects of antibiotics against S. aureus infection. RESULTS: During S. aureus culture, α-toxin levels increased rapidly but the rate of rise was quickly (within 20 minutes) suppressed by linezolid (25 µg/mL). Penicillin also reduced the increase in α-toxin levels; however, the time course was relatively slow compared to linezolid even at high concentrations (50,000 U/mL). The efficacy of penicillin (250,000 U/mL) at reducing the rise in α-toxin was approximately 8% less than that of linezolid (P < 0.05) suggesting the presence of additional toxin. This could be due to a delayed action of penicillin, and/or release of a small pool of stored α-toxin from dying bacteria. In a bovine cartilage model, however, there was no difference between the protection of in situ chondrocytes against S. aureus by penicillin or linezolid (P > 0.05). CONCLUSION: The results suggested that equally effective protection of chondrocytes against S. aureus septic arthritis may be obtained by the bacteriostatic or bacteriolytic antibiotics tested.

The relation between acute changes in the systemic inflammatory response and circulating thiamine and magnesium concentrations after elective knee arthroplasty.

Thiamine diphosphate (TDP) and magnesium are co-factors for key enzymes in human intermediary metabolism. However, their role in the systemic inflammatory response (SIR) is not clear. Therefore, the aim of the present study was to examine the relation between acute changes in the SIR and thiamine and magnesium dependent enzyme activity in patients undergoing elective knee arthroplasty (a standard reproducible surgical injury in apparently healthy individuals). Patients (n = 35) who underwent elective total knee arthroplasty had venous blood samples collected pre- and post-operatively for 3 days, for measurement of whole blood TDP, serum and erythrocyte magnesium, erythrocyte transketolase activity (ETKA), lactate dehydrogenase (LDH), glucose and lactate concentrations. Pre-operatively, TDP concentrations, erythrocyte magnesium concentrations, ETKA and plasma glucose were within normal limits for all patients. In contrast, 5 patients (14%) had low serum magnesium concentrations (< 0.75 mmol/L). On post-operative day1, both TDP concentrations (p < 0.001) and basal ETKA (p < 0.05) increased and serum magnesium concentrations decreased (p < 0.001). Erythrocyte magnesium concentrations correlated with serum magnesium concentrations (rs = 0.338, p < 0.05) and remained constant during SIR. Post-operatively 14 patients (40%) had low serum magnesium concentrations. On day1 serum magnesium concentrations were directly associated with LDH (p < 0.05), WCC (p < 0.05) and neutrophils (p < 0.01). Whole blood TDP and basal ETKA increased while serum magnesium concentrations decreased, indicating increased requirement for thiamine and magnesium dependent enzyme activity during SIR. Therefore, thiamine and magnesium represent potentially modifiable therapeutic targets that may modulate the host inflammatory response. Erythrocyte magnesium concentrations are likely to be reliable measures of status, whereas serum magnesium concentrations and whole blood TDP may not.ClinicalTrials.gov: NCT03554668.

Emergency department at the cutting edge.

OBJECTIVE: This paper reviews the experience of penetrating chest trauma over a 3-year period in one UK emergency department. METHODS: A retrospective review was performed of patients assessed in the emergency department resuscitation room between 1 January 2002 and 31 December 2005. Patients with penetrating chest trauma, either isolated or in combination with other injuries, were included. A Medline search was performed using the terms 'chest', 'trauma' and 'penetrating'. RESULTS: A total of 120 patients presented with penetrating chest trauma. Ninety-two percent were male. Ninety-six percent (115) of the patients survived to hospital discharge. Seventy-eight percent of the patients presented at night (20.00 and 8.00 h). A single wound accounted for 52% (63) of patients, multiple wounds 43% (52) with 2% (two) gun-shot wounds and 3% (three) impalings. The mean prehospital time of patients in cardiac arrest was 42 min with a mean on-scene time of 24 min. The mean prehospital time for patients undergoing formal emergency surgery was 39 min with a mean on-scene time of 16 min. Twenty-three patients required one or more tube thoracostomies to be performed in the emergency department and six underwent emergency department thoracotomy. Sixteen patients required immediate formal emergency surgery for haemorrhage control. CONCLUSION: Penetrating chest trauma contributes significantly to our trauma workload with a high proportion of patients sustaining life-threatening injuries requiring immediate intervention. Significant prehospital delays occur. Overall mortality of 4.2% is comparable with that of a major American case series. Further education and protocol development is required to ensure that prehospital and emergency department management of these patients reflects the latest evidence-based guidelines.

"Irritable Hip": Diagnosis in the Emergency Department. A Descriptive Study Over One Year.

Background A 'limping child' commonly presents to the emergency department (ED), often without a history of trauma. It is important that serious underlying pathology is ruled out before a diagnosis of benign irritable hip (IH). The aetiology of IH is not well understood and there may be geographical and seasonal variation. The aim of this study was to determine the basic epidemiology of IH in the Glasgow Population. Methods A retrospective analysis was carried out of all children discharged from the Glasgow Children's Emergency Department from January to December 2016. Relevant discharge codes were determined and patient records screened. Any patient who did not have a discharge code had their presenting complaint and medical record screened. Results A total of 354 patients were diagnosed with IH, of which 319 and 189 were in the Greater Glasgow and Clyde and City of Glasgow catchment areas, respectively. The majority of these patients (n = 254) were diagnosed clinically. The incidence of IH was 177.7 per 100,000 children with a boy:girl ratio of 1.9:1 (209:110). The mean age of presentation was 3.5 years and the recurrence rate was 5.9% (n = 18). There was an increased incidence in spring (n = 111), especially in March (n = 42) and April (n = 40). There was no incidence variation or influence discernible by social deprivation. Conclusion In this population, IH has: (i) an atypical age profile (age distribution shift to younger), (ii) no marked association with social deprivation (in contrast to other studies), and (iii) a 'spring preponderance'. We suggest that most cases can safely be managed in the ED without recourse to further investigations or speciality referral.

Mapping Chondrocyte Viability, Matrix Glycosaminoglycan, and Water Content on the Surface of a Bovine Metatarsophalangeal Joint.

OBJECTIVE: The purpose of this study was to determine if there were variations in chondrocyte viability, matrix glycosaminoglycan (GAG), and water content between different areas of the articular surface of a bovine metatarsophalangeal joint, a common and reliable source of articular cartilage for experimental study, which may compromise the validity of using multiple samples from different sites within the joint. METHODS: Nine fresh cadaveric bovine metatarsophalangeal joints were obtained. From each joint, 16 osteochondral explants were taken from 4 facets, yielding a total of 144 cartilage specimens for evaluation of chondrocyte viability, matrix GAG, and water content. A less invasive method for harvesting osteochondral explants and for processing the biopsy for the assessment of chondrocyte viability was developed, which maintained maximal viability within each cartilage explant. RESULTS: There was no significant difference between the 16 biopsy sites from the different areas of the joint surface with respect to chondrocyte viability, matrix GAG and water content. Pooled data of all samples from each joint established the baseline values of chondrocyte viability to be 89.4% ± 3.8%, 94.4% ± 2.2%, and 77.9% ± 7.8%, in the superficial quarter, central half, and deep quarter (with regard to depth from the articular surface), respectively. The matrix GAG content of bovine articular cartilage was 6.06 ± 0.41 µg/mg cartilage, and the cartilage water content was 72.4% ± 1.5%. There were also no significant differences of these 3 variables between the different joints. CONCLUSION: It is thus reasonable to compare biopsies obtained from different sites, as a biopsy from one site would be considered representative of the whole joint.

Non-paracetamol drug-induced fulminant hepatic failure among adults in Scotland.

BACKGROUND AND METHODS: This study details 30 cases of non-paracetamol drug-induced fulminant hepatic failure (NPDI-FHF) that have presented to the Scottish Liver Transplant Unit since 1992. Using the patients' case notes and a previously constructed database, the demographics of NPDI-FHF in Scotland were studied. The clinical and biochemical features, and the outcome of each individual case were also investigated. RESULTS: Of the 30 patients, 10 died. Our study revealed that antibiotics are the most commonly associated drugs with NPDI-FHF while ecstasy and anti-tuberculous drugs are also commonly implicated. The geographical distribution of referrals mirrors that of the population distribution and NPDI-FHF is not confined to any particular social class. It is, more than twice as common among females than males, however. The incidence is evenly spread across the different age categories, but NPDI-FHF as a consequence of ecstasy ingestion is confined to younger age groups. Ecstasy associated NPDI-FHF was also associated with short latency periods. CONCLUSION: NPDI-FHF is not a common problem in Scotland, but it is a serious problem for those affected and consumes considerable health care resources. Doctors need to be made aware that commonly prescribed drugs may cause fulminant hepatic failure. When a young adult presents with fulminant hepatic failure of sudden onset, ecstasy consumption must be considered.